EMDR Therapy Quarterly

Introduction

The adjunctive use of EMDR with art therapy is in its infancy. Originally developed by Borstein (2009) as a brief adjunctive therapy, she described it as “a focused application of standard EMDR treatment, provided by an EMDR-trained clinician to clients already engaged in some other form of individual psychotherapy with another therapist … In this model, adjunctive EMDR does not replace or interrupt ongoing therapy. It is complementary to the primary therapy relationship, and it is provided in active collaboration with the primary therapist.”

Dr Borstein’s model for brief adjunctive EMDR requires that it is used in addition to and is supportive of the primary psychotherapy treatment, and that it is focused narrowly on the referral issue. There should be active, reciprocal communication and collaboration with the referring therapist. The client should be a well-functioning individual (with no active substance abuse or safety risks) who is committed to ongoing treatment with their therapist. There should be evidence of a clear target or stuck point on which to focus the intervention.

Through its psychodynamic approach, art therapy uses freedom of expression and free association to track the unique story the client brings. In EMDR, we encourage our clients to attune to their images, thoughts and feelings, and to go with whatever is there. In both therapies, the key approach is to privilege the client’s own direction.

In this report, we describe the process of adjunctive EMDR and art therapy over 18 months with a client who experienced maternal abandonment trauma when she was two years old. We show that both approaches enhance the healing of trauma from infancy and any age. The trauma from early in the development of primary relationships, carried through the life of an individual, is distinctive when the lived experience of abandonment categorically informs the template for all other relationships.

A key aim for us in writing this report is to give a voice to our client Sisqui by reflecting on our work together to deepen our understanding of her experiences. In order to treat her with the dignity she deserves, we include her as the central person in this report. As part of this effort, we asked her what she gained from our EMDR sessions. We wanted to reverse Sisqui’s sense of not having been heard by her family and reverse the negative ideology regarding her disability, which research shows is important for mental wellbeing.

Sisqui chose her pseudonym and co-created this report. We all share concerns about protecting her anonymity so biographical details are minimal.

About Sisqui

“I have been paraplegic for the last 15 years following a near-fatal accident. I have use of my arms and hands after suffering major spinal cord injuries. These injuries mean I have to use a wheelchair. I experience nerve pain in my leg, as well as depression, anxiety and a sleep disorder all exacerbated by trauma. I also have suspected mild brain damage which affects my short-term memory. It is not clear to what extent this is trauma-related from childhood losses or caused by the accident. I feel that the lack of empathic involvement from my family has made my recovery more difficult. I experienced a strict religious upbringing.

I chose to take part in adjunctive EMDR therapy because I wanted to take the next step in my self-help journey and heal from traumatic life events.”

The art therapy process

Kate Rothwell

Sisqui has used art therapy to explore and discover aspects of herself that could be expressed visually but were not accessible in words because they were held emotionally at a non-verbal level. Over time Sisqui has become able to articulate these emotions in words enabling us to include them in our report. The process has been necessarily slow, cautious and gentle, leading to a gradual unveiling of gossamer-like layers. Sisqui came to therapy wanting to work on her depression, having experienced a lifetime of broken trust and abuse of mind and body. Through the psychodynamic relationship, we developed an understanding that the artwork could give Sisqui a voice for her experiences. Nurturing the development of more robust layers supported her to build a secure scaffolding whilst deepening her self-awareness.

Sisqui is a highly creative, curious and courageous person who is able to use mark-making to access unconscious aspects of her psyche. She has a natural ability to let the process lead her. Using colour, form, movement and the aesthetic qualities of the media, she has developed an artist’s identity that has enabled her to curate a significant body of work symbolic of a life that has meaning, resilience, emotional range and depth. At times, she uses familiar but unconventional objects in her artwork; such as unusable male catheters she had been wrongly prescribed, cast-off slow-release anaesthetic patches, prescriptions and sewing to communicate highly personal and intimate experiences.

The process of art therapy, though exploratory, was also a means for Sisqui to connect to emotions she had suppressed since infancy. It revealed her sense of self, hidden behind the burden of powerful projections from family and friends since her accident which she had absorbed as if they were hers, but they did not belong to her.

Art therapy for Sisqui became a lifeline and a process of self-discovery in the purest sense of using art materials to reveal an internal world where she could safely channel emotions and feelings, enabling us to make sense of her different parts. Not all these parts of Sisqui were aware of each other, yet they manifested through her artwork. This has enabled more of an integration of herself as a whole person. This was a careful process, so as not to cause Sisqui more distress than she could endure. Sisqui articulated language both verbally and visually and was determined to grow and develop from a terrified infant to a highly creative adult.

After some years, Sisqui seemed to disconnect and then chose to end her therapy. Respecting her decision, I was concerned that a deeper layer (that could not be drilled through with art therapy alone)  could prevent her ongoing development – her physical pain often told us about anxieties and psychological wounds too painful to touch. Namely, fears of abandonment that surfaced when there was a therapy break. Sisqui decided she wanted to try other therapies in her healing journey. During this break, she came to accept what she could not change in others, suggesting that a more mature outlook on her family was forming. She became more independent and could make her own decisions based on her needs, not others’ wants. She also decided to restart art therapy after a significant pause of several months.

Welcoming her back, we discussed the trauma she had identified that went beyond her physical injuries. I felt that after six years of working with Sisqui on complex trauma from multiple events, I had reached the limit of my skills and abilities to help her. It seemed that unprocessed trauma from her early childhood was specifically impacting her relationship with her mother. I knew that EMDR could help, and I recommended Cathy, knowing she was an experienced EMDR and art therapist, as well as a trusted colleague and friend. I had not realised EMDR could be used as an adjunctive process alongside art therapy. With Sisqui’s willingness and determination to continue with EMDR, this became probably the most defining part of her journey.

Sisqui’s approach to self-help

“I have used self-help psychological and body-based approaches online for some time. This is where I first found out about EMDR, and more recently polyvagal theory.

I often reached out for support online but found I could be let down by this informal support. For instance, when practitioners leaked confidential information about me on Instagram. Art therapy has helped me to channel my emotions and feelings in a safe way. I was happy to explore the possibilities of the combined approach of art therapy and EMDR because I wanted to process my experience of trauma stuck in my body through EMDR.”

Special considerations

Sisqui talked about the invisibility and lack of respect she has experienced as a woman with disabilities in our society. She said she didn’t ask for a disabled label, but she got one, with all the stigma and preconceived ideas, and people getting ‘one over on her’ that comes with it. As she shared her experiences, we became ever more aware of the discrimination she faces, increased by her use of a wheelchair. Kate and I kept in mind the inescapable trauma, lack of opportunity and validation accorded to people with disabilities in our society.

As we worked together, a question emerged about the similarity between Sisqui’s trauma of childhood abandonment, and the social isolation and dependency she experienced once she became disabled.

The beginning of the adjunctive journey

Cathy Ward

When Kate contacted me to see if I could offer EMDR to her client, Sisqui, I was delighted. I looked forward to the possibility of collaborating with them as a new initiative for me. I called her as a first step, and then I met her with Kate. Sisqui explained that she hoped to explore her belief that she was holding onto trauma in her body. We arranged for all sessions to take place in Kate’s studio and for us to share the content of our sessions with each other.

I knew that EMDR could be used alongside other main therapies to address specific traumatic legacies. In our discussion, it looked like there was a good fit of expectations across the three of us, which is important for adjunctive EMDR to be successful. I learned from consulting with Dr Borstein that I needed to step aside from the idea that EMDR would be the most important part of the work and understand that the main therapy would be art therapy.

At the time, I was not aware that Sisqui’s decision to turn towards EMDR followed a three-month break away from therapy with Kate. Sisqui had chosen this break when Kate went on leave. Therapist breaks appeared to trigger Sisqui’s ‘rejection detector’, left over from her early childhood experiences of abandonment, which she felt had been repeated throughout her life.

Had I recognised this, I might have been more prepared for her withdrawal from our EMDR sessions, when clear improvements in her confidence and quality of life were becoming apparent; for example, she planned and undertook a microlight flight, which seemed to epitomise her progress. She later captured the experience, creating a beautiful image of her flight in an art therapy session.

The preparation phase

In early 2023, I began using an attachment-focused approach, based on Parnell’s (2013) framework, to create a ‘place that feels safe’ and resource team. Sisqui found this helpful. Through this process, she was introduced to bilateral stimulation which we used to amplify and install positive feelings and experiences. This was particularly successful in sustainably shifting her low mood.

We used McGoldrick’s (2022) repair/rescue protocol, targeting memories from Sisqui’s life at ages two, five, ten and adulthood, interweaving the repair and rescue work at each stage. Revisiting and repairing her memories in this way began to alleviate Sisqui’s anxieties about exploring her trauma memories through the standard EMDR protocol.

At the outset of the work, I hypothesised that Sisqui’s accident and the consequent major adjustments would be the root causes of the trauma she wanted to free herself from. However, this proved not to be the case and these were often overtaken by her deep sense of having been abandoned by her mother. Her mother became seriously ill when she was two, and a lack of emotional support from her parents echoed throughout her life, which continued following the accident.

Sisqui informed us she would prefer to continue EMDR stabilisation, resource, and resilience-building approaches. Later, we used the flash technique to explore further, resulting in her gaining more confidence in her ability to face her fears and boosting her self-esteem and self-confidence.

As Sisqui processed more material with EMDR, she began to experience physical reactions of pain and swelling in her legs. Her concern about the changes in her body occurred as our first break in therapy became imminent. I noticed she had begun to voice frustration and anger at the people and services she was involved with currently and in the past. In an online session, after I had had a minor operation following my holiday break, Sisqui explained she was experiencing a lot of anger and had been ‘shedding’ people. She described ending work with the support staff around her and told me, “I only want people in my life who want me. I want to end our work together. My body is saying ‘no’ to processing things, and I need to listen to my body.”

Though she did not express it explicitly, and did not seem conscious of it, this anger appeared to be about her EMDR work with me and so she decided to end the EMDR work. I recognised that this deep pattern of severing relationships was at the heart of the issues she was attempting to transform. Kate continued to do solid work with Sisqui, naming and confronting the likelihood of her abandonment history having been triggered by the breaks in therapy. Unexpectedly, meeting to plan this collaborative report provided a route back into EMDR therapy.

Resuming EMDR

With Sisqui’s full agreement after restarting, we were able to plan and prepare for breaks, the eventual ending of our work and to target her abandonment history and its impact on her at the centre of our EMDR work.

A session that epitomised the adjunctive process

In the first session following our summer break, Sisqui chose to process a poignant time a decade ago when she had met up with her family. The meeting occurred after a six-month rehabilitation period in hospital following her accident. Since she had previously described her family as being emotionally unavailable, I was expecting her to process the trauma from that vulnerable time. Instead, she described her family meeting as “feeling surrounded by love and care”.

During what turned out to be an extremely moving session, memories arose of the major psychological shifts she had had to make to accommodate her injuries and disability so soon after the accident. She finished the session by processing from the negative cognition, “A big aching loss – a chasm in the ground that can’t go back together again” to the positive cognition, “I am a strong person. I can cope with many things. I’m allowed to have moments of sadness. They don’t last all the time.”

When Sisqui described feeling surrounded by love and care, I realised that she might also be unconsciously referring to ‘the hammock’ of care and support Kate and I had hoped we were offering her.

In my conversation with Kate about this powerful session, she suggested that a strong sense of reunion might be playing out through the memory of when Sisqui first met her family as a disabled person and that it might also be representing the current reunion with Kate and me after our breaks. This was a deep ‘aha’ moment for me, that seemed to capture the richness of the adjunctive process, in which the trauma-focused bodily memory intersected with the current reparative psychotherapeutic process – an enlightening connection between the EMDR and the psychodynamic approach.

Sisqui’s experience

“I have been reprocessing traumatic events using EMDR and bilateral movements, to lessen the long-lasting and rippling impact of complex post-traumatic stress disorder (CPTSD) on myself and in turn on others. Art therapy complemented the EMDR work. Whatever I thought of in EMDR, I reflected in my paintings in art therapy. The EMDR strengthened and empowered me in my self-belief, my standing in my own power, my trust in my instinct, and my trust in myself.

Being open to working with EMDR was a pivotal moment. It was helpful that Kate and Cathy knew each other, and that Kate had recommended Cathy. For me, it was a meeting of three minds. The real benefit is that I can use EMDR and then have an art therapy session the next day to process through art, feelings emerging from the EMDR session.”

“My art therapy images, coming out of my EMDR sessions, were evidence and reference pieces to go back to, always linked to getting to a stronger place in myself. The EMDR allowed the feelings to be, and the art therapy became the aftercare – and both were invaluable.

The art therapy was more relaxing, I could lose myself where time did not exist. Kate recognised that I shared different parts of myself with her and Cathy. It was eye-opening, as was an understanding of internal family systems, the voices I had internalised. It has led to wider perspectives for me, bringing deeper insights.

Kate and Cathy were pillars of strength, able to provide me with a relational hammock or bridge, which was helpful. I felt looked after. I was encouraged to travel wherever my journey took me. Kate and Cathy were able to share diverse ideas, both understanding where I was coming from and what had happened to me.“

Discussion: Building trust over time

The results of our adjunctive sessions were not simple or what we expected. The fact that our client had experienced parental abandonment when she was two years old shaped the whole course of our work. Through the adjunctive therapy, she played out the legacy of this experience by abruptly leaving the EMDR therapy when I took a short break. She had been triggered similarly by ending her sessions with Kate before a planned break. Sisqui restarted her art therapy the year before I began work with her.

EMDR and art therapy

This work shows that EMDR is compatible with art therapy. Both approaches add value to each other. Many similarities emerge which we can learn from. Art therapy is a visceral and externalising expression, using creative mark-making and language that often flows directly from the unconscious – opening us up to hear inner voices we are probably unaware of. It can be messy, poetic and aesthetic – it is not about art skills or making great art!

Art therapy has frequently been used to process trauma (Greenwood, 2011). Like EMDR, it uses images to delve into the experience. A single image can reveal a wealth of relevant and often revelatory information. This image can then be worked on, added to, and transformed as the therapeutic process continues, often alongside powerful emotional expression. In addition to processing trauma, art therapy can also enhance and build upon positive outcomes. As with EMDR, clients can be encouraged to imagine a positive future image of a resolved difficulty, which can lead to new insights and open pathways to growth and change.
A key issue impacting the progress of this therapy, and where it differs from Borstein’s Brief Adjunctive EMDR model, is that it has not been a brief process. EMDR therapy with Sisqui has so far lasted for 20 months.

Kate and I believe that it is the trust we have developed in each other’s professional expertise and our long-term friendship that has been crucial to its successful implementation. This trust has aided the “active, reciprocal communication with the referring therapist” that Borstein (2009) described as necessary for successful adjunctive EMDR, and to avoid potential pitfalls and red flags.  Borstein underlines the danger of ‘splitting’ where the client sets the therapists against each other, or where there are “unbridgeable differences in case conceptualisation” between therapists. We, on the other hand, have found our differences very bridgeable.

Kate has been happy to learn about EMDR through our handover sessions, which have become a rewarding and necessary feature of the work to maintain linked-up thinking and consider emerging themes. The conversations draw on our wide-ranging, theoretical practice and lived experience in a flow that leaves us enriched and inspired. I wonder to what extent the fact that Kate and I both share a common profession (art therapy) has been another reason for the success of the adjunctive work. Kate has not had to explain the theory of art therapy or its connection with the unconscious and the body or convince me of the complex and amazing power of the creativity it nurtures.

Collaborating with colleagues and within safe boundaries with clients enhances creativity and positive outcomes in therapy. Kate and I are working towards an eventual ending for the therapeutic work with Sisqui by managing breaks and exploring the impact of the legacy of the abandonment still present. We want to understand how current events trigger her body and mind so we can revisit the past and, through the therapeutic hammock, help free her from the extent of the complex trauma that has scripted her life. The rich potential for integrating EMDR with other creative models is captured well in the publication EMDR and Creative Arts Therapies by Davis et al. (2023).

Final thoughts from Sisqui

“Endings need to be prepared respectfully and properly with conversations and communication. I want to allow the next chapter of my life to start and stop the mistakes in the past from repeating themselves. I want to learn different ways to communicate, so I’m not misunderstood.

I hope that what I have learned can be used in the future to help me manage my emotions. The abandonment will last forever – but it’s how I am able to manage myself and navigate future relationships that’s important, and how I react and interact with other people. I guess that the things I’ve learned will lessen the impact of how I experience the world in times of uncertainty and when I am at a low ebb. I feel able to bring myself back to a place of calm and control.

I will let go of what I can’t control; for example, what other people think of me. I will use the power of my imagination, as well as my body, to create safety and calmness.”

Cathy Ward is a state-registered art therapist and EMDR therapist working in private practice. Positionality statement: I am a white able-bodied woman, attempting to be actively anti-racist. I am deeply familiar with my embedded sense of white supremacy and ableism that I try to challenge and call myself out on. I have a lived experience of mental illness, a ‘breakdown’ as a young person, that I now see as a gift, an extraordinary empowering ‘breakthrough’. I (believe) I have a highly developed sense of humour, and I treasure my playfulness and happily include it as part of my therapeutic approach. Dr Kate Rothwell is a child and adolescent psychotherapist, parent-infant psychotherapist, supervisor and a state-registered art therapist. Positionality statement: I identify as a white working-class educated Christian woman brought up and schooled in an underprivileged multiracial area of London. Over three decades, I raised three sons while holding clinical and managerial posts in forensic and NHS settings. To ensure my family's security, I pursued higher education and academic interests to a doctoral level. In my 60th year, I was assessed and diagnosed with dyslexia. This and a seven-year commitment to full-time psychoanalysis have helped me understand much about a dogged determination that has informed my lifelong learning against a background of adversity.